Four tips for how to ensure physician documentation supports payer requirements. By Tammy R. Seel, CPC, CPMA, CEMC, CEDC, AAPC Fellow New coders face two major obstacles: understanding the rules and guidelines of the teaching physician setting, and explaining them to the providers. Working for a level one trauma center, with attendings, physician assistants, nurse ...
Oct 18th, 2017
Working remotely or offsite has become the new normal for coders, making the art of communication more important than ever. But with such a large influx of young coders, it’s difficult for many who have grown up with texting as a primary form of communication to remember to use complete words and sentences. As such, ...
Follow best practices to meet annual exam documentation requirements. By Ellen Risotti-Hinkle, CPC, CPC-I, CPMA, CEMC, CFPC, CIMC, CSCG, AAPC Fellow Unlike other evaluation and management (E/M) services in the CPT® codebook, preventive services do not have specific documentation guidelines required to support the service provided. Here’s what you should know to ensure documentation supports ...
Arm against fraud risks EHRs pose, and develop policies to reinforce compliance. Electronic health records (EHRs) make documentation more legible, but they also make it easier to inflate content. Evaluation and management (E/M) documentation is especially prone to EHR shortcomings because of the repetitive nature of these services. Let’s consider the risks and resolutions. Authenticate ...
When provider and payer work together, everyone wins. By Marcia A. Maar, COC, CPC, CRC Clean, accurate provider documentation improves reimbursement. To demonstrate, consider the ideal reimbursement process: A patient comes in for an office visit or service. A provider documents the reason for the visit, which proves medical necessity for services provided on the ...